DEATH CLAIM

							                      BAJAJ ALLIANZ LIFE INSURANCE COMPANY LTD
                    GE Plaza, Airport Road Yerwada, Pune 411006




                                            DEATH CLAIM
                                      (CLAIMANT’S STATEMENT)




         DOCUMENT’S TO BE SUBMITTED :



    1.    CLAIMANT’S STATEMENT
    2.    DEATH CERTIFICATE DULY ATTESTED
    3.    ORIGINAL POLICY DOCUMENT
    4.    MEDICAL ATTENDANT/ HOSPITAL CERTIFICATE
    5.    CONSENT LETTER DULY SIGNED
    6.    BURIAL/CREMATION REPORT
    7.    EMPLOYERS CERTIFICATE
    8.    HOSPITAL CASE SHEETS
    9.    DEATH DISCHARGE FORM
    10.   KNOW YOUR CUSTOMER

    IF DEATH DUE TO Accident/ Suicide/ Murder
    1. PIR/ FIR ( Police Reports duly certified)
    2. POST MORTEM REPORT DULY CERTIFIED
    3. CHEMICAL ANALYSIS REPORT
    4. DRIVING LICENCE




          1.   Photo copies of documents should be attested by Branch Authorities.

          2.   Copies of police reports should be attached by police authorities.




CF0001                                                                               1
                        BAJAJ ALLIANZ LIFE INSURANCE COMPANY LTD
                      GE Plaza, Airport Road Yerwada, Pune 411006




                                        DEATH CLAIM
                                  (CLAIMANT’S STATEMENT)


PARTICULARS OF INSURED:
 Policy No (s)                                       Age / Sex    :

Deceased Name in Full                                Occupation       :

                                                     Annual Income:

                                                     Employer Name/ Address:



Marital Status at time of death                      Time of Death
 Single  Married  Divorced Widowed

Residential Address                                  Telephone No
                                                     (Res)    :

                                                     (Mobile):


Cause of Death    :           Date of Death:        Place of Death:               Address:
                                                        Hospital
                                                        Home
                                                        Others


Name of Illness   :                                 Duration of Illness:


IF THE DEATH WAS DUE TO ACCIDENT:
 Date of accident                                Time of Accident

Brief Details And Place Of Accident :



FIR No. :               Whether the Deceased had Driving License:         (If yes attach copy of DL)


Please give details of consultation(s)      (Please attach separate sheets if required)

Consultation                Name/ Address        Contact No           Diagnosis              Duration

Doctors consulted




Name of the Hospital Where Treated:            Address:

1.

2.

3.

CF0001                                                                                                  2
                          BAJAJ ALLIANZ LIFE INSURANCE COMPANY LTD
                        GE Plaza, Airport Road Yerwada, Pune 411006


Details of Other Policies
 Name of Companies/                 Policy Dates                Policy No               Amount of Policies
 Contact No / Address                                                                     (Sum Insured)




Is the Policy Assigned                 Yes             No

In what Capacity do you Claim                 Nominee      Assignee    Others(Please Spcify)

Are you a major?            Yes       No              If Yes, state Age   _________

Relationship To the Deceased / Insured (Please tick )
Parents                         Siblings                               Friends    
Spouse                          Children                               Relatives 
Colleagues                       Employer                              Others     
Please specify __________________________________________________________________ )

Claimant’s Name and Address (Nominee/ Assignee/ Others): ___________________
______________________________________________________________________

Contact No. of the Claimant              (Res)___________________(Off)____________________________________

BANK DETAILS OF THE CLAIMANTS

Name of Bank ___________________________________Contact No. of Bank __________________________

Account Number___________________________________ Address of Bank            ___________________________


DECLARATION
I / We hereby make a claim to the said assurance with BAJAJ ALLIANZ LIFE INSURANCE COMPANY
LIMITED and agree that the written statement of all the physicians who attended to or treated
the deceased, and all papers furnished in support of this claim shall constitute and they are
hereby made a part of the proofs of death and further agreed that the furnishing of this form
or any other forms supplemental thereto or any acts of enquiry or investigation by the said
Company shall not constitute or be considered an admission by the company that there was an
assurance in force on the life in question nor a waiver of any of its rights or defences.

I/We affirm that we are aware that notwithstanding any provision of law/usage/custom or
convention for the time being in force prohibiting any physician or hospital from divulging
any knowledge or information regarding the deceased assured on grounds of secrecy the company
is authorized to seek such information as the same had been consented by the deceased in his
contract of insurance with the Company.

I / We hereby authorise any physician or other person or any hospital, sanitorium or other
institution to furnish to BAJAJ ALLIANZ LIFE INSURANCE COMPANY LIMITED, any information/
documents that may be required concerning the late ___________________________________________
and the photocopy of this authorisation shall be valid as original.


________________________                                              ___________________________
Signature of Claimant                                                 Signature of Witness
Name:                                                                 Name:             Address:
Address:

CF0001                                                                                                       3